NUR 242 Med/Surg Exam 1 With 100% correct answers 2025-2026 already graded A+

Four Major subgroups of Late Adulthood

65 - 74 young old

75 - 84 middle old

85 - 99 old old

100 and older elite old

Lifestyle and Practice to Promote Wellness older adults

Yearly flu vaccine

pneumococcal vaccine

Shingles vaccine

tetanus and booster every 10 years

wear seat belts

alcohol in moderation

avoid smoking

smoke detectors

prevent falls - waxed floors and scattered rugs

medications as prescribed

avoid OTC medications unless primary care phyisican directs

Yearly physicial

regular exercise

socialization

reminisce

Common health Issues and Concerns older adults

Decreased nutrition and hydration

Decreased mobility

Stress and loss

Accidents - falls most common/MVA

Drug use and misuse

Mental health/cognition problems (including substance abuse)

Elder neglect and abuse

GFTT ( Geriatric Failure To Thrive) Complex Syndrome

Under nutrition

Impaired mobility

Depression

Cognitive impairment

Depression older adults

Most common mental health/behavioral health problem among older adults.

Use Geriatric Depression Scale form

Mood disorder having cognitive, affective, physical manifestations​

Primary (lack of neurotransmitters)

Secondary or situational

Dementia older adults

slowly progresses

generally chronic

intellectual impairment

Most common Alzheimer's

Multi-infarct dementia, the second most common resulting from a vascular disorder

Delirium older adults

Acute and fluctuating onset

results from an unfamiliar place

Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness

Nurse's role in Rehab

Advocate for the patient and family

Create therapeutic rehab milieu

provide whole person patient-centered care

Collaborate with healthcare team for patient outcome and develop care plan

Communicate with effectively with all members of the health care team, patient and family

Evaluate effe​ctivene​ss of plan of care for the patient and family

Use Braden scale - skin break down risk

Safe Patient Handing and Mobility (SPHM)

-Maintain a wide, stable base with your feet

-Put the bed at the correct height - waist level while providing direct care and hip level when moving patients

- Keep the patient or work directly in front of you to prevent your spine from rotating

- Keep the patient as close to your body as possible to prevent reaching

walker - assisted and cane - assisted procedure

- Apply a transfer belt around patients waist

- guide patient to a standing position

- remind patient to place both hands on the walker

- ensure that the patient's body is well balanced

walker teaching

- lift the walker

- move the walker about 2 feet forward and set it down on all legs

-while resting on the walker, take small steps

- check balance

- repeat sequence

cane teaching

- be sure cane is at the height of the patients wrist when the arm is placed at his or her side

- remind patient to place his or her strong hand on cane

- ensure that the patient's body is well balanced

- move the cane and weaker leg forward at the same time

- move the stronger leg one step forward

- check balance and repeat the sequence

Adaptive equipment

buttonhook

extended shoehorn

plate guard and spork

gel pad

foam buildups

hook and loop fasteners

long-handled reacher

elastic shoelaces or velcro shoe closure

SCIP infection - 1

Prophylactic antibiotic received within one hour prior to surgical incision (to establish bactericidal blood and tissue levels by the time the surgical incision is made)

SCIP infection - 2

Prophylactic antibiotic selection for surgical patients (increased risk for surgical infections)

SCIP infection - 3

Prophylactic Antibiotics discontinued within 24 hours after surgery end time (provides benefit without risk)

SCIP infection - 4

Cardiac surgery patients with controlled 6 am postoperative blood glucose (cardiac patients only) To avoid hyperglycemia

SCIP infection - 6

Surgery patients with appropriate hair removal (removal is performed with electric clippers or chemical depilatories) to avoid skin abrasions and increase risk of surgical site infections

SCIP infection - 9

Urinary catheter removed on postoperative day 1 or postoperative day 2 with day of surgery being day zero ( to avoid urinary tract infections)

SCIP infection - 10

Surgery patients with preoperative temperature management (prevent prolonged hyperthermia, which is associated with wound healing, serious cardiac complications, altered drug metabolism, coagulation problems, and higher surgical infections.

SCIP CARD - 2

Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period ( receive beta-blocker prior and continue immediately after surgery)

SCIP Venous Thromboembolism - 1

Surgical patients with recommended venous thromboembolism prophylaxis ordered (reduce complications from postoperative VTE)

SCIP Venous Thromboembolism - 2

Surgery Patients who received appropriate Venous thromboembolism prophylaxis within 24 hours of prior to surgery to 24 hours after surgery ( reduce complications from postoperative VTE particularly among patients undergoing the types of surgeries in which the risk was highest

Chapter 24 - skin layers

- Epidermis

- dermis

- subcutaneous - hypodermis

Epidermis

- protection

- keratin provides protection from injury by corrosive material

- inhibits proliferation of microorganisms because of dry external surface

-mechanical strength through intercellular bonds

Dermis

-provides cells for wound healing

- provides mechanical strength - collagen fibers - elastic fibers - ground substance

- sensory nerve receptors signal skin injury and inflammation

Subcutaneous tissue

- mechanical shock absorber

-energy reserve

- insulation

Skin assessment - lesions

Primary lesions - direct result of a disease process

Secondary lesions - evolve from primary or develop as a consequence of a patient's activity

Skin assessment - Color

- is affected by blood flow, gas exchange, body temperature, and pigmentation. describe by their appearance. Are changes general or confined to one body region

Skin assessment - ABCDE

A - Asymmetry

B- border irregularity

C- color variation within one lesion

D- Diameter greater than 6 mm

E - Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

Changes in Dark skin - cyanosis

- examine lips and tongue for gray color

- examine nail beds, palms, and soles for blue tinge

- Examine conjunctiva for pallor

Changes in Dark skin - Inflammation

- Compare effective area with non affected area for increased warmth

-examine skin of affected area to determine whether it is shiny or taut or pits with pressure

- Compare the skin color of affected area with the same area on the opposite side of the body

- palpate the affected area and compare it with unaffected area to determine whether texture is different (affected area may feel hard or "woody"

Changes in Dark skin - Jaundice

- Check for yellow tinge to oral mucous membranes, especially the hard palate

- examine the sclera nearest to the iris rather than the corners of the eye

Changes in Dark skin - Bleeding

- Compare the affected area with the same area on the unaffected body side for swelling or skin darkening

- if the patient has thrombocytopenia, petechiae may be present on the oral mucosa or conjunctiva

Nail assessment - nail color

White - chronic liver disease or kidney disease - shock - anemia - early arteriosclerotic changes (toenails) - myocardial infarction

Yellow - brown - Jaundice - peripheral lymphedema - bacterial or fungal infections of the nail - psoriasis - diabetes - cardiac failure - staining from tobacco, nail polish, or dyes - long term tetracycline therapy - normal aging (yellow - gray color)

Red - normal finding in dark skinned patients - nevus or melanoma of nail matrix in light skinned patients

Thin red vertical lines - bacterial endocarditis - trichinosis - trauma to nail bed - normal finding in some patients

Blue - Cardiac insufficiency - polycythemia vera - respiratory failure - methemoglobinuria - venous stasis disease (toenails)

Deep Tissue Injury (DTI)

-The intact skin appears purple or maroon

- Blood - filled blisters may be present

- Before the previously listed appeared, the tissue in this area may first have been painful

- other changes that may have preceded the discoloration include that area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue

Stage 1 pressure ulcer

- skin is intact

- area, usually over a bony prominence, red and does not blanch with external pressure

Stage 2 pressure ulcer

- skin is not intact

- there partial -thickness skin loss of the epidermis or dermis

- ulcer is superficial and maybe an abrasion, a blister (open or fluid-filled, or a shallow crater)

Stage 3 pressure ulcer

- skin loss is full thickness

subcutaneous tissue may be damaged or necrotic

- damage extends to fascia, bone, tendon and muscle

- undermining and tunneling may or may not be present

Stage 4 pressure ulcer

-Skin loss is full thickness with exposed or palpable muscle, tendon, or bone

- often excludes undermining and tunneling

- sinus tracts may develop

- slough and eschar are often present or at least part of the wound

Unstageable

- skin loss is full thickness and the base is completely covered with slough, or eschar, obscurring the true depth of the wound

Wet to damp saline moistened gauze

necrotic debris is mechanically removed but with less trauma to healing tissue

Continuous wet gauze

wound surface continually bathed with wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar

Topical enzyme preparations

proteolytic action of thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue

Moisture - retentive dressing

Spontaneous separation of necrotic tissue is promoted by autolysis

Wound - vac - negative pressure wound therapy

can reduce and or close chronic injuries by removing fluids or infectious materials, enhancing granulation. Should be changed every 48 to 72 hours.

Hyperbaric - oxygen therapy (HBOT)

administration of oxygen under high pressure, raising tissue oxygen concentration. Usually received under limb life-threatening wounds such as - burns, necrotizing infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers

patient at risk for pressure injury - cardiovascular status

- presence or absence of peripheral edema

-hand-vein filling in the dependent position

-neck-vein filling in the recumbent and sitting position

- weight gain or loss

patient at risk for pressure injury - cognition and mental status

-level of consciousness

- orientation to time, place and person

- can the patient read a seven word sentence containing three syllables or fewer

patient at risk for pressure injury - condition of skin

- assess skin cleanliness

- observe all skin areas, especially bony prominences and areas in contact with the bed or other firm surfaces

- measure and record any redness or loss of integrity

- photograph areas of concern

- note presence of skin tenting over sternum and forehead

- note moistness of skin and mucous membranes

Patient at risk for pressure injury - with wounds

- remove dressing (noting condition of dressing)

- cleanse wound and remove and compare with previous notations of wound condition

- presence, amount and nature of exudate

- use disposable paper tape measurement to measure wound diameter and depth

- amount (%) and type of necrotic tissue

- presence of granulation/epithelium

- presence or absence of cellulitis

presence or absence of odor

take patients temperature to assess for fever

Patient at risk for pressure injury - understanding of illness and compliance with treatment

-s/s to report to primary care doctor

-drug therapy plan (correct time and dosing)

- ambulation or positioning schedule

- dressing changes/skin care

- nutrition modifications (24-hr diet recall)

Patient at risk for pressure injury - nutritional needs

- change in muscle mass

- lackluster nails, sparse hair

- recent weight loss or more than 5% of usual weight

- impaired oral intake

- difficulty swallowing

- generalized edema

Psoriasis

Chronic autoimmune disorder affecting the skin with exacerbations and remissions. Results from overstimulation of the immune system. activates T-lymphocytes. This can not be cured, often patients can control symptoms

Complications of Immobility

Contractors, foot drop, muscle atrophy

DVT

Constipation

Decreased cardiac output

Disorientation

renal calculi, UTI

Pneumonia

pressure ulcers

Prevention of pressure ulcers

Early identification of high risk patients (Braden scale)

Mental status change and decreased sensory perception

impaired physical immobility, requires assistance with turning and positioning or patients who can not verbalize discomfort

nutritional status: serum albumin < 3.5 and prealbumin levels < 19.5 Consult dietitian

Incontinence and excessive moisture

Informed consent

Surgeon is responsible before sedation is given and surgery is performed

nurses role is to CLARIFY facts and CLARIFY the consent has been signed

an "X" is permitted in patients that cannot write but MUST be witnessed

If patient doesn't understand the physician is to be notified

BLIND patients can sign own consent but need 2 witnesses

In an EMERGENCY, obtaining consent is not imperative, however it is preferred

Pain Assessment

Pain is the 5th VS

assess level and location using pain management tools (0-10 or Faces scale)

self-report is the MOST reliable indicator

ALWAYS believe the patient when they report pain and treat it promptly

Consider referral to pain management for chronic pain

Pre-Op medications

DRUGS - sedatives(hydroxyzine) Hypnotics(lorazepam) anxiolytics(midazolam) opioid analgesics (morphine, hydromorphone) or anticholinergics)

Pre-OP medications given "on call" to surgery. The nurse should:

Properly identify the patient using the armband an asking the patient to state their name and date of birth

make sure the operative permit is signed

administer the prescribed preoperative medication in the correct dose(s)

Raise the side rails, place the bed in lowest position, call light within reach

Types of Anesthesia

General

Regional

General Anesthesia

Used most often in head, neck, upper torso and abdomen

Once patient reaches PACU the nurse should immediately assess for patients airway, adequate gas exchange, and LOC

also assess the rate, pattern and depth of breathing to determine adequacy of gas exchange

RR < 10 may indicate respiratory depression due to anesthetic or opioids

Regional Anesthesia

A type of local anesthesia that blocks multiple peripheral nerves in a specific body region.

immediately following surgery the nurse should check the patients VS, skin temperature, circulation, cp refill (should be < 3 seconds)

Patient controlled analgesia (PCA)

Morphine, fentanyl, and hydromorphone - most common used

the device is programmed to deliver a certain amount of drug (demand dose) within a specific interval (lockout interval) the lockout interval is usually 5-15 minutes

when the patient is cognitively impaired, another method of drug administration should be considered

Transcutaneous Electrical Nerve Stimulation (TENS) unit

Used as an adjunctive treatment for pain

involves the use of battery-operated device capable of delivering small electrical currents through up to the painful areas

The voltage is regulated by adjusting the dial to the point at which the patient perceived a prickly pins and needles sensation

Post-OP

DVT is the most common type of thrombophlebitis. High risk for pulmonary embolism. Develops most often in the legs but can occur in the upper arms

Interventions: patient education regarding leg exercises, early ambulation, adequate hydration, compression stockings, sequential compression devices (SCD's)

Post-OP

wound healing and prevention of infections

assess the surgical incision at least every 8 hours for redness, increases warmth, swelling, tenderness or pain, and the type/amount of drainage

sanguineous (bloody) to serosanguineous to serous (yellow) drainage is normal during the first few days after surgery. Drainage should gradually decrease

Crusting on the incision line, pink color to the incision line, and slight swelling under the sutures/staples is normal

Post-op Risk for post surgical wound

DEHISCENCE

Obesity

diabetes

corticosteriod use

immune deficiency

malnutrition

Post-op

wound EVISCERATION

Call for help and stay with patient

cover wound with sterile gauze soaked in sterile water

do not attempt to reinsert the protruding organ

place the patient in supine position with hips and knees bent

raise the HOB no more than 15-20 degrees

provide support and reassurance to the patient

Sequence of inflammation

Stage 1 - injured tissue and the leukocytes mast cells in this area secrete histamine, serotonin and kinins that constrict the small veins and dilate the arterioles in the area of injury. These changes cause redness and warmth to the tissues

Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape from the damaged cells. Thus, you will see an increase in the neutrophil count

Stage 3 - tissue repair and replacement occur

MIDLINE catheters

peripheral IV access

utilized for short -term therapy (4 weeks or less)

the tip of the midline ends in the axillary vein

should not be used to draw labs

DOES NOT require x-ray for placement

complications of PIV

(peripheral IV) Infiltration

IV becomes dislodged

fluid leaks from the vein to surrounding tissue

discontinue IV and elevate the extremity

apply ice or heat therapy

vesicant medications can cause extravasation if IV infiltrates

Complication of PIV

phlebitis and thrombophlebitis

inflammation of the vein (redness, edema, warmth, pain at site)

discontinue IV

notify physician for treatment

restart IV in the opposite extremity

Central Line Access Devices

All central line access devices terminate in the superior vena cava (PICC line, implantable ports, tunneled and non-tunneled catheters, and central lines)

insertion requires informed consent

need to have a chest x-ray prior to use

PICC line

placed by a PICC certified nurse

used when long-term therapy is needed (up to one year)

always flush with a 10 ml syringe

RN's can remove a PICC line. Have the patient perform the valsalva maneuver, make sure the tip is intact. If discontinuing due to infection, send the tip of the PICC line to the lab for C&S

Implantable ports

surgically implanted in the right or left chest

canoe used for individuals receiving chemotherapy

huber needle is used to access the port at a 90 degree angle

Complications of central Line Access

Central line associated blood stream infection (CLABI)

s/s: localized erythema, tenderness, fever, drainage

can lead to a systemic infection and sepsis

d/c the central line and culture the tip

tx: ABT and antifungals

prevention: meticulous hand washing

Complications of Central Access Device

Air Embolism

Bolus of air enters circulation

potentially fatal

s/s: tachycardia, chest pain, dyspnea, and cyanosis

interventions: trapping the air into the R atrium, turn the client to the left side in trendelenberg position

all lines should be primed prior to use and connections secure when not in use

Complications of central line access

Clotted access

The catheter becomes clogged from either the solution being infused or from insufficient flushing

a thrombolytic can be ordered from the physician to dwell and dissolve the clot

needs to be treated promptly to prevent having to remove the central line

prevention: routine flushing

Complications of central line access

Pneumothorax

Occurs following insertion of the central line

fatal if not treated

s/s: tachypnea, absent breath sounds on the affected side, decreased oxygen saturation, and restlessness

ALWAYS verify placement of a central line with a chest x-ray

TPN Total Parenteral Nutrition

Nutritional status is monitored by checking protein levels, such as albumin and pre-albumin levels

TPN care and maintenance of

check each bag of TPN for accuracy by comparing it with the physician's order (2 nurses to check to prevent errors)

if the TPN solution is unavailable, give 10% dextrose/water (or 20% D/W) until the TPN solution can be obtained

if the TPN administration is not on time, do not increase the rate

Change IV tubing every 24 hours when new bag is hung

dressing change around the IV site should be changed every 48-72 hours

Sickle cell Disease

RBC's are sickle shaped, rigid and clump together. the clumps form assess of sickled RBC's that block blood flow, leads to tissue hypoxia. Repeated episodes of ischemia lead to progressive organ damage

Pain is the most common problem

Sickle cell crisis

pain due to tissue injury caused by poor oxygenation from obstructed blood flow. Pain is severe enough to require hospitalization and large doses of opioid analgesic. concerns about substance abuse can lead to inadequate pain treatment

Care of Patient in Sickle Call Crisis

Give prescribed pain medication

hydrate with normal saline IV, encourage oral intake of fluids without caffeine

administer oxygen

remove restrictive clothing, no blood pressure with external cuff

check circulation in extremities every hour

Vitamin B12 Deficiency

Results from poor intake of foods containing B12

Vitamin B 12 anemia (pernicious anemia) caused by deficiency of intrinsic factor needed for intestinal absorption of B12. Seen in patients with bowel resections, chronic diarrhea, diverticula, tape worms, or overgrowth of intestinal bacteria

s/s: glossitis (a smooth, beefy red tongue) fatigue, weight loss, and pallor or jaundice

Methicillin Resistant Staphylococcus Aureus (MRSA)

Avoid close contact with others until infection clears

sleep in separate bed from others

wash all soiled clothing and linens with hot water and laundry detergent

do not share any personal items

Cellulitis

generalized infection with either staphylococcus or streptococcus and involves deeper connection tissue

infection can spread by scratching or rubbing the skin

can result from a secondary bacterial infection of an open wound or unrelated to skin trauma

localized area of inflammation that may enlarge rapidly if not treated

warm compresses to the area are recommended

treatment with IVABT

Hand Hygiene

wash hands with soap and water when hands are visible soiled or contaminated

not visible soiled may use ABHR

before direct contact with patients wash or use ABHR

Decontaminate hands before putting on sterile gloves, to after contact with patients intact skin (taking a pulse)

Standard precautions

should be used when caring for all patients.

includes: hand hygiene between each patient contact, after removing gloves, after touching bloody, body fluids or secretions, when touching mucous membranes and non-intact skin

Contact precautions

private room, wear gloves when entering the room, wash hands with soap and water when leaving the room, dedicated equipment for patient

C-diff

scabies

impetigo

respiratory syncytial virus (RSV) in infants and children

Airborne Precautions

private room with negative pressure airflow, keep door closed, N95 respirator, patient to wear surgical mask when leaving room a clinical reason

M - measles

T - tuberculosis

V - varicella (including disseminated zoster)

Droplet precautions

Private room, if private room not available, may share with patient having the same infectious disease and microorganism, wear mask when working within 3 feet of the patient, patient to wear mask when leaving room for clinical reasons

S - sepsis/streptococcal pharyngitis

P - pneumonia/pertussis

I - influenza

D- Diptheria (pharyngeal)

E - epiglottitis

R - Rubella

M - Mumps/meningitis

AN _ Adenovirus

Skin cancer prevention

avoid sun exposure between 11 - 3pm

use sunscreens with the appropriate skin protection factor

wear a hat, opaque clothing, and sunglasses

keep a body map of skin spots, scars, and lesions to detect when changes have occurred